If we do not approve the formulary exception request, we will send you a letter informing you of that decision. You may request a review by an independent review organization. The process is explained in our denial letter. Prior authorization and step therapy prescribing criteria Prior authorization is required when you are prescribed certain drugs or supplies before they can be covered. A network provider may request prior authorization if the provider determines that the drug or supply is medically necessary. Prescribing network providers must supply to our plan the medical information necessary for our plan to make the prior authorization determination. Coverage for a prescribed drug or supply that is approved for prior authorization begins on the date our plan approves the request. A list of those drugs and supplies that require prior authorization is available online at kp.org/formulary or you may contact Member Services at 1-877-221-8221. We apply step therapy prescribing criteria, developed by Medical Group and approved by our plan, to certain drugs and supplies. The step therapy prescribing criteria require that you try a therapeutically similar drug (step 1) for a specified length of time before we will cover another drug (step 2) prescribed for the same condition. A list of drugs and supplies subject to step therapy prescribing criteria, and the requirements for moving to the next step drug, are available online at kp.org/formulary or you may contact Member Services at 1-877-221-8221. Prior authorization exception process We have a process for you or your prescribing network provider to request a review of a prior authorization determination that a drug or supply is not covered. This exception process is not available for drugs and supplies that the law does not require to bear the legend "Rx only." Your prescribing network provider may request an exception if the provider determines that the drug or supply is medically necessary. Prescribing network providers must supply to the network pharmacy the medical information necessary to review the request for exception. A coverage determination will be made within 72 hours of receipt for standard requests and within 24 hours of receipt for expedited requests. If the exception request is approved through this exception process, then we will cover the drug or supply at the applicable cost-sharing shown in the Medical Benefits Chart. If the exception request is not approved, we will send you a letter informing you of that decision. You may request a review by an independent review organization. The process is explained in our denial letter. Emergency fill For purposes of this section, "emergency fill" means a limited dispensed amount of the prescribed drug that allows time for the processing of a prior authorization request. You may have the right to receive an emergency fill of a prescription drug that requires prior authorization under the following circumstances: • the network pharmacy is unable to reach our prior authorization department by phone, as it is outside the department’s business hours; or • the network pharmacy is unable to reach the prescribing network provider for full consultation, and RSARX0124 4